The right side of bed

Faced with the prospect of sending patients out of area due to a lack of bed space, South Essex Partnership trust decided it was time for a fresh approach to an age-old problem. Alexis Nolan reports

If you are sending patients out of area because your beds are full, what is the solution? More beds is the obvious answer. But South Essex Partnership trust has taken a different approach - one that includes its interpretation of the Modernisation Agency's 10 highimpact changes - and means it actually needs fewer beds.

'One of the simple questions we asked was why are people going out of area? People will always give you the rationale that we do not have enough beds. I think you have to look beyond that, ' says chief executive Patrick Geoghegan.

'If you have beds There is always a danger you'll fill them up. If you do not change the practice and attitude and how people actually perform and work you will not succeed in anything.' The trust has changed processes and practices to turn around a system too focused on secondary care services to one based on a recovery model, with the focus on care pathways that do not always end - or start - in hospital.

'The big change is about how our staff have changed, ' explains Mr Geoghegan. 'None of this would happen unless we got all of the staff changing how they work. That is from consultants down.' The trust has been working on modernisation for the last two to three years and has used the 10 high-impact changes since they were launched in September last year (see box).

The trust has opened four resource centres over the last two years where consultants, therapists, social workers and nurses provide outpatient services. Those centres will now also be used to provide a recovery service, an essential element in treating people outside of hospitals.

'The model is assessment primarily in the community, preventing people coming into hospital through support from senior clinicians, crisis teams, family support etc. If you do have to come into hospital then it will be for a very short period of time to stabilise you, ' says Mr Geoghegan.

'You will not be sent out until the clinical risk assessment is done and we are satisfied that you can leave hospital. But then we are sending you out into a very interactive intensive recovery service which is going to work with you for about two weeks to get you back on your feet, so then you can go back into mainstream services.' He continues: 'These recovery units are not the old day hospitals where people go and smoke cigarettes, sit around and have one therapy session a day. This is where you go in in the morning and you will be exhausted by 5pm because you will be getting active treatment and care and that will be ongoing.' The catalyst for the latest stage of modernisation was bed usage that reached 108 per cent and out-of-area patient numbers that rose to up to 45 early last year. This was not just problematic for patients who were away from their usual support networks, but also cost commissioners up to£3m a year.

At the same time, crisis teams were coming on stream and the trust wanted funding to develop an eightbed assessment unit. Something had to give. Managers and consultants worked together to set up the new model, using a hard policy of no out-of-area admissions as the main constraint to force change. When the new model went live in August, out-of-area admissions dropped to zero - and have remained at that level since - and bed usage has gradually fallen to 84 per cent.

'For the block contract, we are now containing all of those patients within district. That is purely because of changes in working practice, ' says Mr Geoghegan.

Strictly local Commissioners are happy because they no longer have to bear the cost of out-of-area treatment - all those patients who were out of area have now come back. And even with the cost of investing in the new assessment unit they still have a net saving of around£1m, says trust modernisation director Nigel Leonard.

Even though the assessment unit was not scheduled to open until last month, the trust introduced the concept to working practice last year, redesigning a ward to free up six beds as a makeshift assessment unit. It is a valid question to wonder whether there is still a need for a separate assessment unit when the bed numbers were successfully handled by the hospital, but Mr Geoghegan says it is still needed.

'I think the question is do you need all these beds if you have done so well. And the answer is That is what we are considering, ' he states.

'If We have got our crisis teams, if you have invested in assertive outreach teams, if you have investment in early intervention, if you have investment in the assessment unit etc, one of the questions we are looking at with our clinicians is do we now, on the success of what we have done to date, need to take a really hard look at what we have got left?' Mr Leonard says the trust wants to reduce adult admission beds by one-third by 2007-08. Mr Geoghegan says he wants to see ward bed numbers go down to around 15 or 16 to ensure that investment goes into the community and that the bed numbers are aligned with staffing levels, therapeutic activity and wellresourced inpatient wards.

This has two effects. It helps to keep the investment focused on community-based services. It also helps to motivate acute clinical staff whose co-operation in changing working practices has been essential.

'If you are changing your practice then there needs to be something in it in the long-term for you, ' adds Mr Leonard.

Among those changes is the new policy that no-one will be admitted without seeing a consultant - or at least not without a consultant giving advice - to stop inappropriate admissions authorised by junior doctors. Ward rounds have been increased from the historical once a week to sometimes daily, and certainly on Fridays and Mondays to ensure timely appraisal and good patient flow.

All the senior managers and clinicians on call are sent text messages at 4pm every day to let them know how many beds are available and where they are.

Nipped in the bud

As well as focusing on moving patients out of hospital into recovery as quickly as possible, the trust has also worked on patients not being admitted in the first place or turning up at accident and emergency because of a lack of confidence by the carer in anything else.

Crisis teams are at the centre of this, acting as what Mr Geoghegan describes as a 'funnel' for the patient care pathway. Carers can get in touch directly with crisis teams - the trust is intending to issue mobile phones to carers with the trust's call centre number preprogrammed to give carers confidence in a swift response.

The trust has supplied GPs with a booklet by the trust as an aid to putting the patient on the right care pathway. GPs have the option to mobilise the crisis team directly to patients' homes. If patients are sent to A&E, they will either be admitted or a crisis team will be activated which will assess the person and draw up a whole care package.

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay